Ambulatory Surgery Total Joint Arthroplasty: The Transition of an Inpatient Orthopedic Nursing Unit

Introduction

Medical delivery models have had to undergo multiple shifts to remain financially sound and meet 21st-century challenges. One example is that many surgical procedures have changed to the ambulatory model, with the enhanced recovery after surgery (ERAS) approach to post-operative care increasingly used across surgical specialties, including arthroplasty. This standardized approach emphasizes multidisciplinary care coordination to prepare the patient for surgery, manage physiological stress, and transition to self-care with an emphasis on mobilization. The multidisciplinary pathway is a vital component of a safe and effective ambulatory surgery program [5].

In 2019, our organization updated its total joint arthroplasty (TJA) clinical pathway to achieve uncomplicated clinical recovery and shorter length of stay (LOS) utilizing ERAS best practices. However, the initiation of our 23-hour, fast-track arthroplasty pathway was confounded by challenges relating to COVID-19. In 2021, the program was reinitiated, but LOS benchmarks were not being met. In fact, only 22% of TJA patients who met ambulatory surgery criteria were discharged within the 23-hour target. In early 2022, an interdisciplinary team was formed to improve pathway utilization and reduce delays. The team identified barriers to on-time discharge, including logistics, staff engagement/education, disjointed workflow, and clinical complications.

To mitigate barriers to discharge, a decision was made to convert an inpatient unit serving multiple orthopedic specialties into a dedicated 23-hour stay TJA unit. This unit would serve as an overnight observation unit with specially trained nursing staff. The transition was multifaceted, and the process consisted of multidisciplinary education, changes in staffing patterns, workflow alterations, informatics integration, and biomedical integration. The unit opened in June 2022, which was guided by the ERAS protocols. Due to unforeseen construction, in November 2022, the dedicated unit had to change floors, absorb staff from another unit, and begin taking inpatients as well as ambulatory surgery patients from multiple orthopedic surgical specialties.

Enhanced recovery after surgery is a patient-centered multimodal perioperative care approach [1]. At its core lies a shift in the care delivery model to support and prepare the patient for recovery at home. The ERAS society develops guidelines that aid facilities in implementing and maintaining effective programs. Although ERAS does not purport to create a new approach to a surgical procedure or a novel anesthesia modality, it does package the latest and most evidence-based surgical procedures in a manner that supports early safe discharge [1]. At its heart, an effective ERAS program relies on 4 principles: (1) evidence-based pre-, intra-, and post-operative minimally invasive surgical techniques and opioid-sparing anesthesia approaches, (2) screening of patients to ensure they are healthy enough to safely meet discharge criteria, (3) early preparation and socialization of the discharge plan with continuity of messaging from the time surgery is indicated through discharge, and (4) emphasis on education and empowerment of the patient or caregiver to confidently assume care at home.

According to Hammerberg et al [2], same day TJA can be safe and effective and it can also help institutions widen their net, extending the procedure to patients who may otherwise not consider it. Furthermore, a study conducted by Reddy et al [4] found that there was no statistical increase in post-operative complication or catastrophic events between total hip arthroplasty (THA) performed in the ambulatory surgery setting and those who were admitted for more than 24 hours. An interdisciplinary team made up of nursing, informatics, physical therapy, medicine, operations, and pharmacy was formed to oversee the transition of this dedicated 23-hour stay unit. The team met weekly to gauge progress and solve problems as they developed.

Logistics

The first identified barrier to discharge was logistics. Historically, dispersing ambulatory TJA patients throughout the hospital was cumbersome. Although nursing personnel have always cared for patients with a variety of needs and goals, mixing complex orthopedic patients with ambulatory TJA patients resulted in poor nurse buy-in and low rates of meeting LOS goals. The specialized care, strong patient education, early mobilization, and empowerment required to implement a 23-hour TJA program made it an obvious decision to convert one inpatient unit to a dedicated 23-hour stay unit. Early application of the inclusion/exclusion criteria found within the ambulatory TJA pathway is crucial. This affords the multidisciplinary team an opportunity to optimize the patient for surgery if possible and begin early education.

Because ERAS relies heavily on patient education and preparation, nursing plays a key role [3]. Once a patient is identified as being appropriate for the ambulatory TJA pathway, socialization of the plan including discharge planning, prehab, and patient optimization can begin. Consistency in messaging of timeline and discharge goals help patients conceptualize their recovery and empower them to assume care at home. The patient education class was altered to support the socialization of the plan and help manage patient and caregiver expectations. To support the staff, the patient status and expected discharge time was added to the patients’ story board in the electronic medical record (EMR). This armed the staff with crucial information such as expected discharge time and contact information for the patient’s escort. In addition, a decision was made to allow the nursing staff to text the patients’ escorts directly from the EMR, saving valuable time.

Staffing was staggered to support off-hours discharges and a high volume of mid-day admissions and discharges. To support altered discharge patterns, several disciplines provided assistance. Physical therapy shifted its staffing to accommodate evaluation and treatment sessions earlier in the day and later in the evening. In addition, nursing staff were trained to have patients up and ready for their sessions, especially those who would be discharged early. The nutrition team offered early trays for those with early discharges and bagged lunches for those leaving around mid-day. Pharmacy prioritized medications for ambulatory TJA patients, thus mitigating another potential barrier to discharge. Finally, biomedical integration had to take place to ensure the unit had adequate monitoring capabilities to accommodate continuous pulse oximetry and EMR integration.

Education and Engagement

The second identified barrier to discharge was staff education and engagement. Early ambulation can mitigate a multitude of post-operative complications that can become barriers to discharge; these include pain, post-operative urinary retention, constipation, nausea, atelectasis, and delirium. A study conducted by Yakkanti et al [6] found that early and rapid mobilization following total knee arthroplasty led to a significant reduction in LOS and improved patient disposition at discharge. Nursing staff were re-educated by physical therapy on sensory motor assessments and mobilization to increase their confidence in ambulating their patients on post-operative day 0. To accommodate patients with early discharge times, nursing staff were empowered to critically think and advocate for early labs and imaging. Both nursing and ancillary staff were given scripting to support discharge within the ambulatory surgery timeline and convey confidence in the patient’s ability to recover at home. In addition, refresher classes and in-services on the 23-hour TJA pathway, obstructive sleep apnea, discharge process, safe car transfer, ambulatory care, and arrhythmia review were completed.

Roadblocks

This project encountered a roadblock when it was forced to change course due to unforeseen construction. In this case, the dedicated 23-hour stay unit was forced to change locations, absorb staff from a different unit, and begin cohorting inpatients and ambulatory patients from different orthopedic surgical specialties. In addition to supporting the staff to accommodate this change, the absorbed staff needed to undergo the same education that the original staff had completed. Because the new unit no longer had the same bedside monitoring capabilities, the entire staff had to be educated on the new bedside monitoring device.

Length of Stay

Prior to the initiation of the dedicated 23-hour stay unit, an average of just 22% of eligible patients met LOS goals. After the unit’s inception in June 2022, this increased to over 40%. By October 2022, nearly 60% of eligible TJA patients met LOS goals. Following the construction and relocation of the unit, there was a slight decrease in the number of patients who met the LOS goal, but the total volume of cases increased by nearly 20%. Even after the unit opened to inpatients and ambulatory orthopedic patients from other orthopedic specialties in November 2022, the multidisciplinary team continued to follow the ERAS principles in caring for identified 23-hour stay TJA patients. Since then, nearly 50% of eligible TJA patients have achieved the 23-hour-stay benchmark.

Conclusions

Enhanced recovery after surgery proved to be an effective model to reinitiate our ambulatory TJA pathway and to oversee the transition of an inpatient nursing unit to a dedicated 23-hour stay TJA unit, from June to November 2022. As a result of ERAS protocols on a dedicated unit, an increased number of eligible patients met LOS goals. Finally, the geographical relocation of the unit, absorption of staff from another unit, and cohorting of both inpatients and ambulatory patients from multiple orthopedic specialties did not lead significantly reduce the number of eligible patients meeting LOS goals. Our findings and our journey could serve as the basis for future scientific inquiry into the impact of a dedicated ambulatory TJA unit on LOS.

Supplemental Material

sj-docx-1-hss-10.1177_15563316231210869 – Supplemental material for Ambulatory Surgery Total Joint Arthroplasty: The Transition of an Inpatient Orthopedic Nursing Unit

Supplemental material, sj-docx-1-hss-10.1177_15563316231210869 for Ambulatory Surgery Total Joint Arthroplasty: The Transition of an Inpatient Orthopedic Nursing Unit by Jake White in HSS Journal®